List of MALT fields and values - Surgeons

Updated September 2020

Morbidity Audit Logbook Tool (MALT) list of fields and values This dataset matches that recommended for audit in the RACS ‘Surgical Audit and Peer Review Guide’

* These fields can be made Mandatory or Optional by a MALT System Administrator, for each logbook type.

** These fields are Mandatory for all cases

Case Details: Expanded Dataset

Field Name Type Values

Case Details: Minimum Dataset

First name* Text Free text

Last name* Text Free text

URN/NHI* Text Free text patient identifier from hospital medical record

Date of birth* Date field

Age* Number (automatic)

Field is auto-calculated if the Date of Birth field is populated. Alternately, an age can be entered as free text.

Hospital name** Drop down

Single select

User pre-selects the hospitals they wish to be available for this data point, from a full list of all Australian and New Zealand hospitals available in their Account screen. Optionally, a default hospital can be setup also. (Some overseas hospitals are available and additional ones can be added by a MALT System Administrator on request.)

Unit/Clinic Drop down

Single select

User pre-selects the hospital surgical unit or private clinic from a list populated by the MALT System Administrator. Additional values can be set up on request.

Rotation Period** Drop down

Single select

Field used by Surgical Trainees, International Medical Graduates and Fellows subspecialising to define the reporting periods for their training/assessment program.

Values are defined by the MALT System Administrator and differ specialty to specialty, country to country and state to state.

SET Level Drop down

Single select

Used by Surgical Trainees only. If applicable, a default SET level can be set up by the User in their Account settings.

PGY Level Drop down

Single select

Used by JDocs only. If applicable, a default PGY level can be set up by the User in their Account settings.

Procedure date** Date field

Supervisor Read only field Displays supervisor name as set up by the user in their Account settings. The full list of supervisor names is sourced from the College membership database.

Alternate approver* Type ahead

Single select

Select from the list that has been set up by the user in their Account settings. The full list of supervisor names is sourced from the College membership database.



Start Time (theatre record) Time field

End time Time field

Duration Number (automatic)

(hours and minutes) Field is calculated on Start/End time fields

Gender Drop down

Single select

Male

Female

Ethnicity

Drop down with type-ahead search. Multi-pick.

Australian

Australian - Australian Aboriginal

Australian - Australian South Sea Islander

New Zealander

New Zealander - Maori

Melanesian and Papuan

Melanesian and Papuan - New Caledonia

Melanesian and Papuan - Ni-Vanuatu

Melanesian and Papuan - Papua New Guinean

Melanesian and Papuan - Solomon Islander

Micronesian

Micronesian - I-Kiribati

Micronesian - Nauruan

Polynesian

Polynesian - Cook Islander

Polynesian - Niuean

Polynesian - Samoan

Polynesian - Tongan

Polynesian - Hawaiian

Polynesian - Tahitian

Polynesian - Tokelauan

Polynesian - Tuvaluan

Polynesian - French Polynesian

British

British - English

British - Scottish

British - Welsh

British - Channel Islander

British - Manx

British - Falkland Islander

Irish

Western European

Western European - Austrian

Western European - Dutch

Western European - Flemish

Western European - French



Western European - German

Western European - Swiss

Western European - Belgian

Western European - Frisian

Western European - Luxembourg

Northern European

Northern European - Danish

Northern European - Finnish

Northern European - Icelandic

Northern European - Norwegian

Northern European - Swedish

Northern European - Greenlandic

Southern European

Southern European - Basque

Southern European - Catalan

Southern European - Italian

Southern European - Maltese

Southern European - Portuguese

Southern European - Spanish

Southern European - Gibraltarian

South Eastern Europe

South Eastern Europe - Albanian

South Eastern Europe - Bosnian

South Eastern Europe - Bulgarian

South Eastern Europe - Croatian

South Eastern Europe - Greek

South Eastern Europe - Macedonian

South Eastern Europe - Moldovan

South Eastern Europe - Montenegrin

South Eastern Europe - Romanian

South Eastern Europe - Roma/Gypsy

South Eastern Europe - Serbian

South Eastern Europe - Slovene

South Eastern Europe - Cypriot

South Eastern Europe - Vlach

Eastern European

Eastern European - Belarusan

Eastern European - Czech

Eastern European - Estonian

Eastern European - Hungarian

Eastern European - Latvian

Eastern European - Lithuanian

Eastern European - Polish

Eastern European - Russian



Eastern European - Slovak

Eastern European - Ukrainian

Eastern European - Sorb/Wend

Arab

Arab - Algerian

Arab - Egyptian

Arab - Iraqi

Arab - Jordanian

Arab - Kuwaiti

Arab - Lebanese

Arab - Libyan

Arab - Moroccan

Arab - Palestinian

Arab - Saudi Arabian

Arab - Syrian

Arab - Tunisian

Arab - Yemeni

Arab - Baggara

Arab - Bedouin

Arab - Omani

Jewish

Other North African and Middle Eastern

Other North African and Middle Eastern - Assyrian/Chaldean

Other North African and Middle Eastern - Berber

Other North African and Middle Eastern - Coptic

Other North African and Middle Eastern - Iranian

Other North African and Middle Eastern - Kurdish

Other North African and Middle Eastern - Sudanese

Other North African and Middle Eastern - Turkish

Other North African and Middle Eastern - Nubian

South-East Asian

South-East Asian - Anglo-Burmese

South-East Asian - Burmese

South-East Asian - Hmong

South-East Asian - Khmer

South-East Asian - Lao

South-East Asian - Thai

South-East Asian - Vietnamese

South-East Asian - Karen

South-East Asian - Mon

South-East Asian - Filipino

South-East Asian - Indonesian

South-East Asian - Javanese

South-East Asian - Madurese



South-East Asian - Malay

South-East Asian - Sudanese

South-East Asian - Timorese

South-East Asian - Acehnese

South-East Asian - Balinese

South-East Asian - Bruneian

South-East Asian - Kadazan

South-East Asian - Singaporean

South-East Asian - Temoq

South-East Asian - Irian Jayan

South-East Asian - Sumatran

Chinese Asian

Chinese Asian - Chinese

Other North-East Asian

Other North-East Asian - Japanese

Other North-East Asian - Korean

Other North-East Asian - Mongolian

Other North-East Asian - Tibetan

Southern Asian

Southern Asian - Anglo-Indian

Southern Asian - Bengali

Southern Asian - Burgher

Southern Asian - Gujarati

Southern Asian - Indian

Southern Asian - Malayali

Southern Asian - Nepalese

Southern Asian - Pakistani

Southern Asian - Punjabi

Southern Asian - Sikh

Southern Asian - Sinhalese

Southern Asian - Tamil

Southern Asian - Maldivian

Central Asian

Central Asian - Afghan

Central Asian - Armenian

Central Asian - Georgian

Central Asian - Kazakh

Central Asian - Pathan

Central Asian - Uzbek

Central Asian - Azeri

Central Asian - Hazara

Central Asian - Tajik

Central Asian - Tatar

Central Asian - Turkmen



Central Asian - Uighur

Central Asian - Chechen

North American

North American - African American

North American - American

North American - Canadian

North American - French Canadian

North American - Hispanic

North American - Native North American Indian

North American - Bermudan

South American

South American - Argentinian

South American - Bolivian

South American - Brazilian

South American - Chilean

South American - Colombian

South American - Ecuadorian

South American - Guyanese

South American - Peruvian

South American - Uruguayan

South American - Venezuelan

South American - Paraguayan

Central American

Central American - Mexican

Central American - Nicaraguan

Central American - Salvadoran

Central American - Costa Rican

Central American - Guatemalan

Central American - Mayan

Central American - Honduran

Central American - Panamanian

Caribbean Islander

Caribbean Islander - Cuban

Caribbean Islander - Jamaican

Caribbean Islander - Trinidadian (Tobagonian)

Caribbean Islander - Barbadian

Caribbean Islander - Puerto Rican

Caribbean Islander - Bahamian

Caribbean Islander - Grenadian

Caribbean Islander - Haitian

Central and West African

Central and West African - Akan

Central and West African - Ghanaian

Central and West African - Nigerian



Central and West African - Yoruba

Central and West African - Ivorian

Central and West African - Liberian

Central and West African - Sierra Leonean

Central and West African - Kongo

Southern and East African

Southern and East African - Afrikaner

Southern and East African - Angolan

Southern and East African - Eritrean

Southern and East African - Ethiopian

Southern and East African - Kenyan

Southern and East African - Malawian

Southern and East African - Mauritian

Southern and East African - Mozambican

Southern and East African - Oromo

Southern and East African - Seychellois

Southern and East African - Somali

Southern and East African - South African

Southern and East African - Tanzanian

Southern and East African - Ugandan

Southern and East African - Zambian

Southern and East African – Zimbabwean

Southern and East African - Amhara

Southern and East African - Batswana

Southern and East African - Dinka

Southern and East African - Hutu

Southern and East African - Masai

Southern and East African - Nuer

Southern and East African - Tigrayan

Southern and East African - Tigre

Southern and East African - Zulu

Southern and East African - Namibian

Other

Unknown

Admission Date Date field

Admission Category Drop down

Single select

Elective

Emergency

Day case

Unplanned readmission < 28 Days

Non-Admited

Unplanned Readmission Drop down

Single select

No

Yes – Pain

Yes – Bleeding



Yes – Electrolyte imbalance

Yes – Infection

Yes – Pulmonary embolism

Yes – Intra-abdominal collection

Yes – Organ failure

Yes – Other causes

Funding Type Drop down

Single select

Private – ACC funded (NZ)

Private – funded (NZ)

Private – health insurance funded

Private – self funded

Public

Traffic (Aus)

Veteran (Aus)

Workcover (Aus)

Diagnosis Date Date field

Pre-management Diagnosis

Type ahead

Multi-pick

Terms from the SNOMED Problem/Diagnoses Reference Set maintained by ADHA

Recognised co-morbidities

(based on extracts from the Elixhauser and Charlson systems)

Drop down Multi pick

Acquired brain injury

AF

Alcohol abuse

Alzheimer’s disease

Anaemia - blood loss

Anaemia – deficiency

Angina pectoris

Anxiety

Associated syndrome

Asthma

Benign prostatic hypertrophy

Birthweight < 1000 grams

Bleeding disorder – VWF, Haemophilia, thrombocytopaenia

CABG

Cancer - lymphoma

Cancer - metastatic

Cancer - solid tumour without metastasis

Cardiac arrhythmia

Cholilithiasis

Chronic pulmonary disease

COAD

Coagulopathy

Congenital heart disease

Congestive heart failure

Connective tissue disorder

http://www.ihtsdo.org/snomed-ct/what-is-snomed-ct

https://www.digitalhealth.gov.au/




Current smoker

CVA/TIA

Dementia

Depression

Diabetes (complicated)

Diabetes (uncomplicated)

Diabetes – IDDM

Diabetes - NIDDM

Drug abuse

Epilepsy

Ex-smoker

Extreme prematurity <28/40

Fluid and electrolyte disorders

Gallstone pancreatitis

Gout

GORD

Gynaecological malignancy

Haemodialysis

Hepatic Disease

HIV/AIDS

Hypercholesterolemia

Hyperlipidaemia

Hypertension (complicated or uncomplicated)

Hyperthyroidism

Hypothyroidism

Inflammatory arthropathy

Intellectual impairment

Ischaemic heart disease

MI - previous (>30days)

MI - recent (<30days)

Obesity (BMI >32)

Osteoarthritis

Osteoporosis

Other

Other neurological disorders

Paralysis

Parkinson’s disease

Peptic ulcer disease excluding bleeding

Peripheral vascular disorders

Permanent pacemaker

Prematurity

Previous DVT/PE

Previous lower abdominal surgery

Previous pelvic surgery



Psoriasis

Psychosis

Pulmonary circulatory disorders

Renal failure

Rheumatoid arthritis/collagen vascular diseases

Schizophrenia

Steroid therapy

Valvular heart disease

Warfarin therapy

Weight loss

ASA Grade Drop down

Single-select

I - Normal Healthy Patient

II - Mild Systemic Disease

III - Severe Systemic Disease

IV - Severe Systemic disease that is a constant threat to life

V - Moribund patient who is not expected to survive without operation

VI - A declared brain-dead patient whose organs are being removed for donor purposes

Wound Infection Risk Drop down

Single-select

Clean

Clean/contaminated

Contaminated

Dirty

Other

N/A

Type of Anaesthetic Drop down

Multi-pick

Epidural

General

Local

Regional block

Sedation

Spinal

Prophylaxis Drop down

Multi-pick

Antibiotics

DVT prevention

Final diagnosis Type ahead

Multi-pick


Pathological Diagnosis Type ahead

Multi-pick








Unplanned ICU Admission Drop down

Single select

No

Yes – Localised sepsis (wound)

Yes – Generalised sepsis

Yes – Pneumonia

Yes – Renal failure

Yes – Arrhythmia

Yes – Myocardial infarction

Yes – Other cause

Yes – Pulmonary embolism

Return to Theatre Drop down No

Yes – Bleeding

Yes – Collection

Yes – CSF Leak

Yes – Wound sepsis

Yes – Other organ/structure injury

Yes – Wound dehiscence

Yes – Other cause

Discharge Date Date field

Outcome Drop down

Single select

Died

Discharged home

Discharged for care or respite

Transferred for more complex care

Absconded/took own discharge

Referred to other services

Mortality Classification Drop down

Single select

[Only available if Admission Outcome = Died]

Death due to complications of comorbidities

Death due to complications of surgery

Possibly preventable death

Unavoidable death with one or more substandard factors in care

Unavoidable expected death

Recurrence date Date field

Discussed at MDM Drop down

Single select

Yes

No

Comments Text Free Text, multiple values allowed


Procedural Minimum Dataset: All Procedures

Procedure Name

[multiple procedures can be entered against a single case]

Type ahead

Single select

SNOMED Logbooks:

Type ahead will search the synonyms and name from the MALT SNOMED Surgical Reference Set.

Users can also have additional procedures added on request by contacting the MALT Help Desk.

Non-operative management

[multiple instances of non-operative management can be entered against a single case]

Type ahead

Single select

SNOMED Logbooks:

Type ahead will search the terms and synonyms in the SNOMED Problem/Diagnosis Reference Set.

Level of supervision Drop down List of supervision levels for the logbook type: ALL Fellows: Primary Surgeon – PS Assisting (srubbed) – AS Observing (not scrubbed) – ONS Available – A SIMGs: Cardiothoracic Surgery Assisted – B First Assistant – C Unassisted - A General Surgery Partial Primary Operator - PPO Surgeon Mentor in Theatre – S2 Surgeon Mentor Available – S3 Assisting Surgeon Mentor – A1 Assisting Senior Registrar – A2 Neurosurgery Primary Surgeon – PS Secondary Surgeon – SS Assistant Surgeon – AS Orthopaedic Surgery Surgeon Independent – SI Surgeon Supervised – SS Assistant - A Otolaryngology Head & Neck Surgery Supervisor in theatre not scrubbed – S2 Supervisor scrubbed in theatre – S1 Supervisor on call – S3 Assist/Observe senior surgeon - AO Paediatric Surgery Assistant – A Observer – O Primary Surgeon, Trainer Available – P Primary Surgeon, Training Junior Trainee – T Supervised Surgeon, Trainer in OT – STU



Supervised Surgeon, Trainer Scrubbed - STS Plastic Surgery Surgeon alone – SA Mentor available – MA Mentor scrubbed – MS Assistant - A Urology Open Primary Surgeon – OPS Open Secondary Surgeon – OSS Open Assistant Surgeon – OAS Vascular Surgery Primary - P Assistant – A Assisting Trainees - AT SETs: Cardiothoracic Surgery Trainee Unassisted – A Trainee Assisted – B Trainee First Assistant - C General Surgery Surgeon Mentor Scrubbed – S1 Surgeon Mentor in Theatre – S2 Surgeon Mentor Available – S3 Partial Primary Operator - PPO Assisting Surgeon Mentor – A1 Assisting Senior Registrar – A2 Neurosurgery Primary Surgeon – PS Secondary Surgeon – SS Assistant Surgeon – AS Orthopaedic Surgery (Aus) Surgeon Independent – SI Surgeon Supervised – SS Assistant - A Orthopaedic Surgery ( NZ) Assistant – A Supervised – S Unsupervised – U Observed – O Otolaryngology Head & Neck Surgery Supervisor in theatre not scrubbed – S2 Supervisor scrubbed in theatre – S1 Supervisor on call – S3 Assist/Observe senior surgeon - AO Paediatric Surgery Primary Surgeon, Training Junior Trainee – T Supervised Surgeon, Trainer in OT – STU Primary Surgeon, Trainer Available – P



Supervised Surgeon, Trainer Scrubbed – STS Assistant – A Observer – O Paediatric-General Surgery SET2&3 Assistant – A Observer – O Primary Surgeon, Trainer Available – P Primary Surgeon, training junior trainee – T Supervised Surgeon, Trainer in OT – STU Supervised Surgeon, Trainer Scrubbed - STS Plastic Surgery (Aus.) Surgeon Alone – SA Mentor Available – MA Mentor Scrubbed – MS Assistant – A Plastic Surgery (NZ) Surgeon Alone – SA Mentor Available – MA Mentor Scrubbed – MS Assistant – A Urology Open Primary Surgeon – OPS Open Secondary Surgeon – OSS Open Assistant Surgeon – OAS Vascular Surgery Primary Surgeon– P Assistant – A ANZTBCRS Surgeon Mentor Scrubbed – S1 Surgeon Mentor in Theatre – S2 Surgeon Mentor Available – S3 Surgeon Supervising Registrar – S4 Assistant Surgeon – S5 Gastric & Oesophageal Surgery Surgeon Mentor Scrubbed – S1 Surgeon Mentor in Theatre – S2 Surgeon Mentor Available – S3 Assisting Surgeon Mentor – A1 Supervising Junior Surgeon – SJ Hepatic, Pancreatic & Biliary Surgery Surgeon Mentor Scrubbed – S1 Surgeon Mentor in Theatre – S2 Surgeon Mentor Available – S3 Assisting Surgeon Mentor – A1 Supervising Junior Surgeon – SJ J-Docs Independent -1 Supervised – 2 1st Assistant – 3 2nd Assistant – 4 Observed - 5



Global Health Primary Surgeon – PS Assisting (scrubbed) – AS Observing (not scrubbed) – ONS Available - A Affliate Logbook Primary Surgeon – PS Assisting (scrubbed) – AS Obsserviing (not scrubbed) – ONS Available – A Surgeon Supervising – SS BreastSurgANZ Primary Surgeon – PS Assisting Surgeon – AS Maintenance of Professional Standards (MoPs) Primary Surgeon – PS Assisting (scrubbed) – AS Obsserviing (not scrubbed) – ONS Available – A

Outcome (non-operative procedures only)

Drop down

Single select

Died

Discharged home

Transferred to another service

Transferred to another hospital

Procedural Expanded Dataset: All Procedures

Magnitude Drop down

Single select

Complex

Intermediate

Major

Minor

Urgency Drop down

Single select

Elective

Emergency

Planned Day Case

Unplanned readmission

Urgent

Complications Drop down

Single select

Abandoned TURP

Abdominal Pain

Abdominal/pelvis collection

Acute Brain Syndrome

Acute Renal Impairment

Aesthetic major

Aesthetic minor

Anaemia

Anaesthetic complication

Anastomotic leak

Anastomotic Leak (bowel)

Anastomotic Leak (ureteroileal)

Anastomotic revision

Arrhythmia

Atrial Fibrillation

Avulsed ureter

Bile duct - retained stone



Bile duct injury

Bile leak requiring intervention

Bile leak settling spontaneously

Bladder Wall Perforation extraperitoneal vs transperitoneal

Bleeding - Haematoma

Bleeding - Postoperative Haemorrhage

Bleeding - Requiring intervention or hospitalisation

Bleeding requiring haemostatic therapy

Blocked / Dislodged SPC (requiring operation)

Blood Transfusion

Bowel Obstruction Requiring Surgery

Cardio-respiratory instability

Cardiovascular - Cardiac Arrest

Cardiovascular - CVA / TIA

Cardiovascular - Myocardial Infarction

Cardiovascular - Myocardial Ischaemia

Cardiovascular - Stroke

Chest Infection

Clinical anastomotic leak

Compartment syndrome

Confusion Episode

Conversion to Laparotomy

CSF

CVA

Damage to other viscus

Dehydration - IV rehydration

Diabetes Mellitus (exacerbation)

Diarrhoea - antibiotic related

Diarrhoea - infective

Dislocation

Dural Tear

Electrolyte imbalance

Enterocolitis

Enterocutaneous fistula

Epilepsy

Exacerbation arthritis / gout

Exacerbation of Dementia

Failed Embolisation

Failed PUJ repair Open

Failed stone removal

Failed Trial of Void

False Urethral Passage

Fat necrosis

Fistula

Fixation failure

Flap failure complete

Flap failure partial

Fractured stent

General - Adverse Drug Reaction

General - Confusion

General - Death

General - Fall

General - Fall with fracture



General - Fever requiring hospitalisation for IV antibiotics

General - Unplanned return to theatre

Genitourinary - UTI requiring further antibiotics but not IV

Graft failure complete

Graft failure partial

Haematuria - postoperative clot retention

Haemorrhage - return to theatre

Haemorrhage - transfusion required

Hepatobiliary (Bile leak, cholecystitis etc.)

Hernia

Hydronephrosis - nephrostomy / stent

Hypospadias fistula

Ileus / Bowel Obstruction (conservative)

Implant failure / extrusion

Infection - Abscess (not wound infection)

Infection - Cannula site

Infection - Clinically significant local

Infection - MRSA

Infection - VRE

Intra-abdominal abscess

Intraoperative fracture

Intussusception perforation

Intussusception recurrence

Laparoscopic Conversion to Open - Adhesions

Laparoscopic Conversion to Open - Failure to progress

Laparoscopic Conversion to Open - Organ Injury

Laparoscopic Conversion to Open - Vascular Injury

Laparoscopic Intraoperative complication (other)

Lymphatic system (chyle leak etc.)

Lymphocoele

Major organ dysfunction - Acute renal failure

Major organ dysfunction - ARDS

Major organ dysfunction - Cholestatic jaundice

Major organ dysfunction - Hepatic failure

Major organ dysfunction - Multi-organ

Major organ dysfunction - Shock or hypotension requiring inotropic support

Malunion

Metabolic / Electrolyte imbalance

Nausea / Vomiting

Neobladder prolonged leak

Nephrostomy - blocked

Nephrostomy - dislodged

Nerve injury

Neurological defecit

Neuropraxia / pressure area

Nipple Necrosis

Non union

None

Obturator Nerve Injury

Other

Pain Syndrome

Pancreatic Abscess



Pancreatitis

PCNL Adjacent organ injury (eg colon)

PCNL Damage to Kidney requiring prolonged drainage

PCNL Embolisation

PCNL Haemorrhage requiring transfusion

PCNL Prolonged haematuria

Perforation

Peripheral vascular disease

Pleural effusion

Pneumothorax (chest drain)

Postoperative atelactasis

Postoperative Corr Calcium less than 2.0mmol/L

Postoperative fever >48hrs

Postoperative Haematoma

Postoperative Haematoma - Conservative

Postoperative Haematoma - Conservative Drainage (open or percutaneous)

Post-operative haemorrhage

Postoperative ileus

Post-operative intra-abdominal infection

Postoperative pain requiring referral to pain clinic

Postoperative Pain requiring stent insertion

Postoperative Urinoma - Conservative

Postoperative Urinoma Drainage (open/percutaneous)

Post-operative wound infection

Pressure sores

Procedure abandoned

Prolonged length of stay

Pseudo obstruction

Pseudocyst

Pulmonary Embolus

Pyloromyotomy perforation

Radiological anastomotic leak

Rectal Injury - oversewn

Rectal Injury - stoma and reoperation

Renal Failure Requiring Dialysis

Reoperation unplanned

Respiratory - Pneumonia

Respiratory Failure

Retained Stent

Retention of urine

Sepsis - Bacteraemia/septicaemia

Sepsis - Endocarditis

Sepsis - Line related

Sepsis - Septic shock

Septacemia

Seroma

Sinus

Small bowel obstruction

Splenectomy

Stent / Nephrostomy - dislodged

Stent syndrome/stent removal

Subphrenic abscess



Superficial wound dehiscence

Temporary recurrent laryngeal nerve palsy

Tendon rupture

Thromboembolism

Thrombosis - DVT

Thrombosis - PE

Total wound dehiscence

TURP syndrome

Unplanned ICU admission

Unplanned readmission after discharge

Ureteric Injury

Ureteric perforation

Ureteric transection

Urethral Stricture

Urethral Stricture late comp

Urethrolysis for retention post incontinence procedure

Urinary Retention

Urinary tract infection

Urinoma / Collection / Abscess - drainage

Urosepsis

Use of reversal agents (naloxone and flumazenil)

Wound breakdown or dehiscence

Wound erythema

Wound excessive bleeding

Wound infection (discharge of pus)

Wound infection requiring further surgery

Complications grade

[Clavien Dindo grading]

Drop down

Single select

CD1: Deviation from normal postoperative course without need for surgical, radiological, endoscopic or pharmacological interventions, EXCEPTING anti-emetics, anti-pyretics, analgesics, diuretics, electrolytes, physiotherapy & wounds opened at bedside

CD2: Requiring pharmacological treatment (other than that allowed for CD1), including blood transfusion or TPN

CD3a: Complication which necessitates intervention, surgical, endoscopic or radiological, NOT REQUIRING GENERAL ANAESTHESIA

CD3b: Complication which necessitates intervention, surgical, endoscopic or radiological, REQUIRING GENERAL ANAESTHESIA

CD4a: Life threatening complications requiring ICU management: SINGLE ORGAN DYSFUNCTION, INCLUDING DIALYSIS

CD4b: Life threatening complications requiring ICU management: MULTIORGAN DYSFUNCTION

CD5: Death

No Complications

No specified grade

Follow-up date Date field



Follow-up findings and plan Free text

Primary Surgeon Drop down

Single select

Yes

No

Note: many procedures in MALT have additional fields associated with them, and more can be added on request. For example, colonoscopy and gastroscopy have additional fields associated with measuring the success of the procedure, and some cancer related procedures record TNM staging data.

Documents

List of MALT fields and values - Surgeons